Leave Behind Narcan Form (for anyone seeking substance abuse support)
Please fill out the info below for the person receiving the Leave-Behind Kit
Incident Number (if applicable)
Station or Unit Number
*
Individuals's Phone Number (to be shared with Harm Reduction Services for follow-up)
*
-
Area Code
Phone Number
Individuals's E-Mail
Incident Location (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Individual's Address (if different than incident location)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of doses dispensed
2 (one bag)
4 (two bags)
6 (three bags)
8 (four bags)
10 (five bags)
There are two doses per bag
Kit ID Number
*
A22
B22
C22
D22
E22
F22
G23
H23
I23
J23
K23
L24
Found on front of red bag
Reason for naloxone
Self Use
Family Member
Friend
Preparedness
Preferred not to answer
Age
Gender
Male
Female
Unknown
Race
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other
Clinican Name
*
In case we need to reach you
Notes (No PHI Please)
Submit
Should be Empty: